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Pharyngeal gonorrhoea: the forgotten reservoir
  1. M Janier,
  2. F Lassau,
  3. I Casin,
  4. P Morel
  1. STD Clinic, Hopital Saint-Louis (Paris), France
  1. Correspondence to:
    Dr Michel Janier;

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Urethral gonorrhoea (UG) dramatically decreased in Paris between 1986 and 1997 as a consequence of safer sexual behaviour. Thus, only 43 cases of gonorrhoea have been collected in our clinic in 1997, the lowest number since the early 1970s. Since 1998, an increase has been observed, as in other STD clinics in France and in the Renago laboratory network.1–,3 Men who have sex with men (MSMs) represent an increasing number of men with UG. Many of them are HIV seropositive and recognise unprotected oral sex as the only risk factor for gonorrhoea. This finding prompted us to study pharyngeal carriage of Neisseria gonorrhoeae (NG) and Neisseria meningitidis (NM) in this population.

From January 1999 to May 2001, 200 consecutive cases of male UG were observed in our clinic; a pharyngeal smear for culture of NG and NM was suggested as well as a standardised questionnaire aimed at sexual behaviour; 178 gave informed consent. Results are presented in table 1, comparing MSMs and men who also have sex with women (MSWs).

Interestingly, MSMs represent more than 50% of patients with UG (compared to 10% in 1986 and 20% in 1995). One third of them are HIV seropositive (a minimal figure because of a high rate, 9%, of test refusal). Fifty eight per cent admitted unprotected oral sex as the sole risk factor for gonorrhoea. Moreover, 98% of the gonococci cultured in MSMs are serogroup W-2–3 (v 73 % in MSWs) and only 1/92 produce penicillinase (v 26 % in MSWs), suggesting a homogeneous cluster of strains circulating in the Paris gay community (study ongoing). Finally, pharyngeal carriage of both NG (14%) and NM (20%) is high.

Data concerning MSWs are heterogeneous, UG affects mainly male patients from north (35%) and central (31%) Africa, with oral sex as the only risk factor for gonorrhoea (10%), and pharyngeal carriage of NG and NM (6%) is much lower, but not inconsistent.

Pharyngeal gonorrhoea is mostly asymptomatic (all our cases were) and bacteriological diagnosis is uncertain, but we believe that the pharynx acts as an important reservoir accounting for the recent increase in UG, particularly in MSMs using unprotected oral sex as an alleged safer sex act. The high proportion of HIV infected patients is a major cause of concern and information about the hazards of unprotected oral sex is warranted.

Table 1

Urethral gonorrhoea (UG)